1. Hazard Identification: / Foreman Name: ______/ PTSA
Pre-Safety Task Analysis
David H. Martin Excavating
Circle the potential hazards associated with this task / Date: ______Time: ______
Strains/Sprains – Pinch Points – Slips/Trips – Falls / Was anyone injured or did an unplanned incident occur today? q Y q N
Burns – Asbestos – Lead – Mercury – Sharp Edges
Noise – Atmosphere – Electric Shock -- Rigging – / If yes, please explain:
Stored Energy – Combustible Material – Body Positioning
Dismantling/Demolition – Line of Fire /
List additional Hazards: ______/ Was the incident reported to the HSE Department? q Y q N q N/A
2. Barriers and Signs:
Required barriers installed? q Y q N q N/A / Is the work area clean and free of debris from the day’s work? q Y q N
Required signage posted? q Y q N q N/A / What near misses occurred, if any?
3. Tools and Equipment
Have users inspected tools, ladders, electrical cords, and
Safety equipment? q Y q N
Do you have the right tools approved to perform your job safely and efficiently? q Y q N / Step 10: Reviewers / Step 1: General Information
Foreman/Supt ______/ Job # Name: ______
If NO, – DO NOT START until you have the correct tools! / HSE Department: ______/ Foreman: ______
4. Housekeeping Requirements: / Step 11: Management Participation / Date: ______/ Time: ______
Are trash receptacles placed in area? q Y q N q N/A / Name: ______/ Task Location: ______
Is material storage area identified? q Y q N q N/A / Task Description: ______
5. Hazardous Materials: / ______
Hazardous material concerns with this task? q Y q N / Step 12: Post STA Signatures / ______
Safety Data Sheet (SDS) available? q Y q N / 1. ______/ ______
6. Safety at Heights: / 2. ______/ OVERVIEW
The STA process is an integral part of David H. Martins HSE Culture. The interactive process requires that management, supervision, and ALL employees:
· Define the general task for each day’s activity
· Identify know and potential HSE hazards associate with the task
· Determine work practices to complete the task safely
· Address requirements for all personal protective equipment needed during the task
· Are empowered to continuously participate in this process, revising the plan when conditions change during the task (this can be something as simple as weather conditions)
RETURN TO HSE DEPARTMENT
Falling object protection required? q Y q N / 3. ______
Are barricades required? q Y q N / 4. ______
7. Ladders / Scaffolds / 5. ______
Correct Ladder identified for this task? q Y q N q N/A / 6. ______
Ladders / Scaffolds inspected? q Y q N q N/A / 7. ______
Designated Competent Person: ______/ 8. ______
8. Fall Protection: / 9. ______
Fall protection required for this task? q Y q N q N/A / 10. ______
Approved tie-off points identified? q Y q N q N/A / 11. ______
Fall Protection Equipment inspected? q Y q N q N/A / 12. ______
9. Welding / Cutting / Grinding: / 13. ______
HOT WORK PERMIT obtained? q Y q N / 14. ______
Step 3: Personal Protective Equipment / Step 4: Permits/Tags/Signs/Documents / Step 8: Names of ALL Contractors
Clothing / Hearing Protection / q Hot Work / q Crane Lift / SIGN IN
q Reflective Vest / q Ear Plugs / q Trenching/Excavation / q Scaffolds
q High Vis Shirt / q Ear Muffs / q Confined Space / q SDS / 1. ______
q Chemical Resistant / Foot Protection / q Line Break / q Roof Work / 2. ______
Eye / Face Protection / q Hard Toed Boots / q Hot Tap / q Floor Removal / 3. ______
q Safety Glasses with / q Rubber Boots / q Lockout / Tagout / q Guardrail Removal / 4. ______
Side Shields / q Metatarsal / q Signs / Barricades / q Hazardous Material / 5. ______
q Goggles / q Steel Toe / 6. ______
q Face Shield / Hand Protection / Employee Certifications / 7. ______
q Welding Hood / q General Purpose / q Crane Operator / q Forklift Operator / 8. ______
Head Protection / q Leather / q Trackhoe Operator / q Vehicle Operator / 9. ______
q Hard Hat / q Cut Resistant / q Powder Actuated Tool User / 10. ______
Fall Protection / q Level ______/ q Heavy Equipment / Crane Signalman / 11. ______
q Full Body Harness / q Chemical / q Rigger / q Flagger / 12. ______
Lanyard Type: ______/ q Rubber q Latex / COMPETENT PERSON DESIGNATION / 13. ______
q Heat Resistant / q Ladder / q Scaffold / 14. ______
Respirator: q Voluntary q Required / q Excavation / q Confined Space / By signing here, I proclaim that I have read and understand.
q PAPR q APR q Dust q ½ Facer q Full Face / q Demolition / q Fall Protection
Step 5: General Task Assigned / Step 6: Potential Hazards / Step 7: Safe Work Practices
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IDENTIFY YOUR FIRST AID KIT, SAFETY SHOWER, FIRE EXTINGUISERS, and EMERGENCY EQUIPMENT LOCATION